Kris English, PhD

The University of Akron/NOAC

We get so busy. We have much to accomplish in an appointment, slightly on auto-pilot but the conversation seems to be going well, and then …

…the patient (or parent) breaks eye contact. She looks at the floor, or her hands, or the door (no mystery what that likely means), or at nothing in particular. Do we notice? If we notice, do we pause? Or do we keep talking and ignore the nonverbal cue?

Patient and parent interactions seem so routine, it is easy to overlook the underlying dynamics, although medicine has studied them for years (Finset, 2016).  A starting point for audiology is the consideration of eye contact – a simple concept but not much discussed in our literature.  So let’s consider it now:

Question #1  How many times during an appointment does a patient or parent break eye contact? As a profession, we don’t know. As professionals, we probably have never noticed.

Question #2  Why do patients break eye contact? What does it mean when a patient looks away from our face, or withdraws from our joint attention on devices or forms? We can’t be sure, but the patient is probably thinking about/feeling something new. Perhaps he is trying to process what we are saying. Perhaps a wave of emotion has interrupted his ability to concentrate. Perhaps our conversation triggered a memory, a doubt, a worry, a question, a regret, a recognition of embarrassing-but-real vanity (Kajimura & Nomura, 2016).

Question #3  What do we do when a patient or parent looks away?  As members of Western culture, our instinct is likely to keep talking, because we are socialized to move the conversation forward and avoid awkward silences. And yet as we do so, we must realize that (1) we are wasting effort because the patient is not listening, and (2) we are missing a potential opportunity to help. At this moment, something weighs on this person’s mind and heart, and if allowed an extra moment, he may wish to share it. However, by forging ahead, we unwittingly violate a basic principle of patient-centered care. Continue reading →

John Greer Clark, PhD

The University of Cincinnati

Several years ago, our university went through, what seemed at the time, a major upheaval as we transitioned from a quarter-based institution to the more conventional semester system. In the process several courses in our department that had previously been separate were combined. In subsequent years my teaching of counseling and audiologic rehabilitation have become intertwined which has led to a more hands on, practical learning of both topics.

Preparation of future clinicians within our profession is likely not that different than in other professions in many ways. I am sure that we are not unique in the dilemma that classroom teaching does not always reflect what students practice in their clinical settings. In the 1960s and 1970s we ardently argued that the full management of hearing loss, including the dispensing of products to assist those with hearing deficits, could indeed be done ethically. And we argued that we were the best prepared to provide this service and that we could do it better. I do believe we are better prepared and can fully service those with hearing loss more effectively than other hearing health care professions. However, it is dismaying that we largely adopted the dispensing practices already in place and have not substantially deviated from these over the years to incorporate better use of personal adjustment counseling and to address more fully the rehabilitative needs of patients.

In the classroom, I teach hearing aid fitting and the continued post-fitting needs of the patient with a strong counseling emphasis. My students frequently tell me what I already know: that this is not what is seen in their practicum sites. They seem to have forgotten that I forewarned them of this.

Every Patient’s Story Matters

Clinically, we still fail to engage our patients in the telling of their stories. We believe we can most often predict the impact of hearing loss from the audiogram (Pietrzyk, 2009). But even if we could predict the impact, these are our patients’ stories and our patients have the right to tell their stories to an empathic listener who can guide them through considerations of the impact of the hearing loss through self-assessment measures. While more introspective than other animal species, humans frequently lack the ability to be fully introspective of limitations they do not want to admit or fear to confront. It is normal human nature to avoid what can be perceived as uncomfortable discussions relative to displayed emotions and frustrations. Students need experience in the classroom and in the clinic with broaching these discussions and working toward effective solutions with patients. The teaching of effective hearing loss impact exploration, and using this within motivational engagement work with patients, is now a large part of my combined counseling and audiologic rehabilitation class. Continue reading →

Karen Muñoz, EdD

Utah State University

The importance of counseling is well recognized for the vital role it plays in audiology service delivery. There are text books devoted to counseling (e.g., Clark & English, 2014), and continuing education opportunities for interested professionals. Counseling is included in audiology scopes of practice (ASHA, 2004; AAA, 2004), and audiology preferred practice guidelines (ASHA, 2006). It sounds like as a profession we have this covered. But do we?

Even though there is agreement on the foundational role counseling plays in audiology service delivery, the lack of depth in professional practice guidelines leaves expectations for graduate training vague. Counseling competencies, just like other skills audiologists learn, need intentional instruction for knowledge and skill acquisition. Similar to student learning for other evidence-based audiology services, bridging of knowledge is needed between coursework and clinical experiences. For this to occur, clinical supervisors need to be intentionally practicing and teaching evidence-based counseling skills. Without careful attention to counseling training, it is unlikely that graduate students will be purposeful in their approach to counseling. You may be thinking, of course counseling is happening, why would this be a problem that needs attention?

Counseling Skills: Not a Given

Patients have shared their experiences with audiologists and it is clear that counseling ability does not just happen to develop along the way. Parents have reported gaps in the information and support they received (e.g., Larsen et al., 2012; Muñoz et al. 2013). Hearing aid uptake among adults with hearing loss is low (Kochkin, 2009), but influential factors are not well defined. There is a need for further research to better understand the influence of factors such as audiologists’ counseling skills, patient self-efficacy, and overall type and quality of interactions between the audiologist and patient (Knudsen et al., 2010). Recent research has also raised concerns with how counseling conversations are happening in audiology. Analysis of audio-recorded appointments with adult clients considering hearing aids revealed that audiologists responded to client psychosocial concerns with technical information, ignoring the emotional content of concerns raised (Ekberg et al., 2014). During history-taking, in a related study, audiologists often interrupted the client early on, and then maintained verbal dominance during the appointment (Grenness et al., 2014).

Patient Centered Care

Patient-centered care is widely recognized as an important feature of healthcare delivery that can lead to improved outcomes and adherence with recommendations (Robinson et al., 2008; Zolnierek & DiMatteo, 2009). Patients seeking audiology services, not surprisingly, also want services that are patient-centered (Laplante-Lévesque et al., 2014). It may seem that being patient-centered should occur if the practitioner values it and is aware, but awareness alone is not sufficient for changing behavior (Muñoz et al., 2015). Counseling is more than being a caring and compassionate professional, and while the skills needed to provide effective counseling are not necessarily difficult to learn, they are not intuitively implemented. Just think about a time when you did not feel heard, or were not given an opportunity to voice your thoughts, or were told how to fix your health concern.

Focus and Feedback

Effective use of counseling skills requires knowledge about behavior and factors that influence behavior (yours and your patients), opportunity to practice implementing skills, and performance feedback. In other words, it needs to be intentionally taught, just like other skills in audiology such as completing a diagnostic test or troubleshooting hearing aids. Teaching counseling in our graduate training programs needs to be approached from an evidence-based perspective. Audiology would benefit from clear evidence-based counseling guidelines that provide a consistent message about the purpose, indicate needed knowledge and skills, and training considerations for classroom and clinical experiences. Teaching counseling in audiology is in need of attention and further research to improve educational practices, implementation of skills, and most importantly, to positively influence client and family outcomes.

References

American Academy of Audiology. (2004). Scope of practice.

American Speech-Language-Hearing Association. (2004). Scope of practice in audiology. 

American Speech-Language-Hearing Association. (2006). Preferred practice patterns for the profession of audiology.

Ekberg K, Grenness C, & Hickson L. (2014) Addressing patients’ psychosocial concerns regarding hearing aids within audiology appointments for older adults. American Journal of Audiolology, 23, 337-350. doi:10.1044/2014_AJA-14-0011

Clark, J.G., & English, K.M. (2014). Counseling-infused audiologic care.Boston: Pearson.

Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2014). Communication patterns in audiologic rehabilitation history-taking: Audiologists, patients, and their companions. Ear & Hearing, 36, 191-204.

Knudsen, L.V., Oberg, M., Nielsen, C., Naylor, G., & Kramer, S.E. (2010). Factors influencing help seeking, hearing aid uptake, hearing aid use and satisfaction with hearing aids: A review of the literature. Trends in Hearing, 14(3), 127-154.

Kochkin, S. (2009). MarkTrak VIII: 25-year trends in the hearing health market.

Laplante-Lévesque, A., Hickson, L., & Grenness, C. (2014). An Australian survey of audiologists’ preferences for patient-centeredness. International Journal of Audiology, 53:sup1, S76-S82.

Larsen, B., Muñoz, K., DesGeorges, J., Nelson, L., & Kennedy, S. (2012). Early Hearing Detection and Intervention: Parent experiences with the diagnostic hearing assessment. American Journal of Audiology, 21, 91-99.

Muñoz, K., Blaiser, K., & Barwick, K. (2013). Parent hearing aid experiences in the United States. Journal of the American Academy of Audiology, 24(1), 5-16.

Muñoz, K., Nelson, L., Blaiser, K, Price, T., & Twohig, M. (2015). Improving support for parents of children with hearing loss: Provider training on use of targeted communication strategies. Journal of the American Academy of Audiology, 26(2), 116-127.

Robinson, J.H., Callister, L.C., Berry, J.A., & Dearing, K.A. (2008). Patient-centered care and adherence: definitions and applications to improve outcomes. Journal of American Academy of Nurse Practitioners, 20, 600-607.

Zolnierek, K.B.H., & DiMatteo, M.R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Med Care, 47(8), 826-834. Doi: 10.1097/MLR.0b013e31819a5acc

(Recent comment by an AuD graduate who has been practicing for several years)

Judith Blumsack, PhD

Associate Professor Emerita

Auburn University

Those of us who teach counseling to Au.D. students can look to a variety of sources as we develop coursework. Descriptions of approaches used by professional counseling educators, colleagues in other health professions who are teaching counseling, and our own colleagues are available to us, and efficacy studies in audiology are beginning to appear (e.g. English & Archbold, 2014). During the time I taught counseling, I used a variety of learning activities. I have no efficacy research to report, but perhaps my experiences with these learning activities and my thoughts about them might be of interest to readers of this forum.

Inviting Visitors to the Class: Patients

Patients and Parents as Guest Speakers

One of the learning activities I used involved inviting patients to visit the class. Each semester, through networking, I located patients who would be willing to join the counseling class for our afternoon group meeting. I should mention that our class met once each week and was three hours long to avoid constraints imposed by the standard 55 minute class session. In scheduling patient visits each semester, I arranged for one of the visitors to be an adult with hearing loss and one visitor to be a parent of a child with hearing impairment. We began each session by briefly introducing ourselves individually and asking the visitors to then do the same. The visitors, though, would keep talking. They would tell us things they thought would be helpful for students to hear. These visits were all memorable, and sometimes they were very moving. The visitors understood that the purpose of their visit to our class was to create a situation where they would be the teacher while the student, with no white coat on, could truly be a student and not a student clinician. Students were encouraged to ask questions. The visitors knew that they could decline to answer a question if they wished, but it is notable that, without exception, the visitors seemed to welcome the opportunity to share their experiences. Here was a situation where listening and understanding was the very purpose of the encounter, not testing, not interpreting results, not making recommendations…….just listening. It was my hope that the students would learn not only about the specifics of that visitor’s experience, but that they would see that patients have much to teach them.

Inviting Visitors to the Class: Professional Counselors

Continue reading →

Kris English, PhD

The University of Akron/NOAC

Back in the day (mid-1980’s), like all Master’s degree students in the US at the time, I took a typical course in Adult Aural Rehab. For some reason I remember this little pop quiz:

I was ready for the question and jotted down the answers:

1. take a case history
2. conduct tests
3. report test results
4. make recommendations.

I got an A on the quiz, confident I had the world by the tail, eventually graduated and worked in the field… and immediately realized that my answers, although not wrong, were not enough. I was assuming that all patients were ready to accept my recommendations and would follow up accordingly. And of course, that was not happening. There were days when only a few patients moved forward with hearing help. Patients were far more complicated than I had expected, and I wasn’t factoring in any of those complications. I didn’t even know what those complications were.

There was no terminology for my approach at the time, but now I know it can be called audiologist-centered (i.e., it was all about me). Consistent with my quiz answers, I expected to direct the appointment, while the patient passively followed my lead. I didn’t intend to be disrespectful or dismissive of the patient’s role, but I held a naïve (some would say paternalistic) assumption that patients had no say because they didn’t know what I knew, and I knew best. In reality, of course adult patients are anything but passive: they are autonomous beings and they will make decisions with or without our involvement (Tauber, 2005).

In contrast to my first efforts, patient-centeredness is a concept that has now made it to “center stage” (Epstein & Street, 2010) and is considered one of the Institute of Medicine’s (2001) six key elements of high quality care. The IOM defines patient-centered care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (p. 6). This kind of care requires dialogue, not monologue, and even further, the ability to develop relationships and partnerships. Today, my quiz answers would be worth a “C” grade at best.

Other Assumptions?

Another assumption that surely should be reconsidered is related to my third answer above (report test results), specifically regarding our beloved audiogram. As important as it is to us, should we assume that all patients are also equally fascinated? More than twenty years ago, Martin (1994) challenged this assumption, and yet in a recent workshop, a participant mentioned that in her 20 years of practice, it had not once occurred to her to ask this question. So let’s think about it:

1. Do all patients really want a crash course in audiology?
2. If not, what do they want from us?
3. If they do prefer specific information, how do we know if we are sharing information effectively?

As we apply patient-centered principles to our audiologic practices, it seems long overdue to examine the practice of unquestioningly explaining the audiogram to every patient or caregiver. Apart from habit and training, why do we do this? Is it really necessary? Is it actually meaningful? Should we give patients a choice, or do we truly believe they cannot leave the appointment without a tutorial in audiogram interpretation? Is the exercise a worthwhile use of time?

When we examine this “auto-pilot” practice, even more questions emerge. What would happen if we do give patients a choice, and ask if they would prefer a “big picture” summary or the details?   If they choose “big picture summary,” will we freeze up? Do we use the audiogram as a prop, or can we put our test results to one side, use simple terms to clearly relate the findings to their initial concerns, and move on?

Patient-Centeredness = Patient Choice

Undoubtedly, some patients will appreciate the time spent reviewing test results, and will understand them. But we cannot assume this is always the case, and to date we also cannot consider it an evidence-based practice.  As a deeply-held tradition, reconsidering its value causes a surprising amount of angst.  But the point of patient-centeredness is, it’s not about us!

References

Epstein, RM & Street, RL. (2010). The values and value of patient-centered care. Annuals of Family Medicine, 9(2), 100-103.

Institute of Medicine. (2001). Crossing the quality chasm : A new health system for the 21st century. Washington, DC: National Academy Press.

Martin, F.N. (1994). Conveying diagnostic information. In J. G. Clark & F. N. Martin (Eds.), Effective counseling in audiology (pp. 38-67) Needham Heights, MA: Allyn & Bacon.

Tauber AI. (2005). Patient autonomy and the ethics of responsibility. Cambridge, MA: The MIT Press.